After Star-D: Treatment Resistant Depression

Abstract

Although the lack of evidence in literature for the treatment of resistant depression has not been totally overcome by Star-D Study, and the basic questions are still unanswered; we can assume that now we have much more reliable data regarding the topic. The recent data can be seen as such: 1. The definition of treatment-resistant depression as 'not to have response (or remission) after two appropriate trials of different antidepressants' seems to be true. 2. Antidepressant therapy should start as monotherapy with optimal dose. Most of the patients require 6-8 weeks for response or remission. A dose increase towards the maximal or the highest tolerated dose must start in the 4th week, if there is no response. The same dose can be maintained if there is a partial response. 3. In case of an absolute unresponsiveness in the 6(th) week, switching the antidepressant can be considered after the exclusion of the factors of pseudo-resistance; and a partial response may suggest an augmentation or combination strategy. 4. The predictors of those strategies are unknown yet. For a severe depression it may be safer to choose augmentation or combination instead of switch. For a worsening depression, on the other hand, ECT may be the safest and most correct option. 5. At present, the data show that augmentation and combination have almost the same efficacy in case of resistance. 6. Regarding the available data, T3, lithium or buspirone options can be considered for augmentation. 7. SSRI+bupropione, venlafaxine+mirtaza pine, SSRI+TCA, TCA+mianserine, SSRI+mirtazapine, and SSRI+reboxetine can be seen as options for combination strategy. 8. In regard to switching, venlafaxine, TCA's, bupropione, mirtazapine, and another SSRI seem to be the options in case of an SSRI's failure. 9. Since the available data show that all the medication alternatives have a very limited success after two failures with different antidepressants, considering ECT in that step can be rational. Archives of Neuropsychiatry 2009; 46: 61-9)